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FOCUS CARDIOLOGY: Two Northern California hospitals

Bypass surgery cases on a sharp decline statewide

The number of coronary artery bypass graft surgeries continue to drastically decline year after year as more non-invasive options are available.

And Northern California hospitals appear to perform better on these procedures compared with hospitals in Southern California. There were 12,000 less bypass graft surgeries in 2005, when compared with 2000, according to California Report on Coronary Artery Bypass Graft Surgery, 2005 Hospital Data that was released toward the end of January. During the same period, there was an increase of 8,000 angioplasties with stents.

While stents are a good alternative treatment for heart disease, surgery is frequently recommended for patients with extensive coronary disease, reduced left ventricular function and disease involving the major artery to the heart muscle.

The California Office of Statewide Health Planning and Development published the report in response to a law that was passed in 2001 that requires hospitals to submit its data for analysis. Once the data is submitted to the state, it is put through a rigorous statistical adjustment to account for hospitals, such as academic medical centers, that have patients with multiple complications.

There were 522 deaths among 16,939 isolated bypass surgeries in 2005, with a mortality rate of 3.08 percent, compared to 2.91 percent for 2003 and 3.29 percent during 2004. Nationally, the Society of Thoracic Surgeons reported 2.3 percent mortality rate during the same period, however the national reporting is voluntary and not verified, according to the state report.

"We were disappointed that we didn''t see a decline in the mortality rate compared with the last reported period," said Joseph Parker, director of the healthcare outcomes center, Office of Statewide Health Planning and Development. "We are seeing a reduction in mortality in the 2006 data."

The data isn''t consumer friendly, but often used by physicians, health insurance companies and employers to inform patients on where to go for treatment. "Patient education and improving quality of care is the overall purpose of this report."
The risk-adjusted mortality rate for California hospitals ranged from 0 percent to 11.49 percent revealing wide variation in bypass surgery outcomes. Of the 120 hospitals in the state that offer bypass surgery, 114 performed within 95 percent of their expected range compared to the state''s overall mortality rate, according to the report.
The top two performers in the state are in in Northern California.

Alta Bates had 791 bypass surgery cases with a risk-adjusted mortality rate of 1.69 percent, according to the state report.

"We are very proud of our record," said Dr. Russell Stanten, chief of cardiac surgery at Alta Bates Summit Medical Center. "Our hospital has consistently been recognized as one of the top in the state."

The key to success is being rigorous about frequently collecting data, analyzing the data and making necessary changes to improve where necessary, Stanten said.
Alta Bates is a Sutter Health Hospital that has had a joint heart program with Kaiser Permanente since 2002. The two programs came together when Alta Bates was in financial trouble, and before its affiliation with Sutter Health.

The two physician groups work closely together to operate a seamless heart program. They use national standards for best practices and have routine follow-up with the patients once they leave the hospital, Stanten said.

Since the hospital has gained media attention for having one of the best heart programs, patients are traveling from across the Bay Area to be treated there, Stanten said. "We are proactive to provide the best care we can because we know the information is going to be out in the public domain," Stanten said.

"This is the way health care is going, whether doctors like it or not."

O''Connor Hospital in San Jose had the highest risk-adjusted mortality rate at 6.65 percent. "It appears that we might have an indication that we may have a slightly higher mortality rate," said Dr. Charles Block, chief medical officer at O''Connor Hospital. "But I''d say we are average."

In 2005, O''Connor had 110 bypass surgery cases, but it jumped to 150 cases in 2006. And they are seeing improvements in mortality rates, Block said. O''Connor hired a new heart surgeon, Dr. Sang Lee, in 2006, who has been working to help improve heart care at the hospital.

"I want to see our name move up on the list," Block said. The physicians are pulling together various departments including cardiology, radiology and others to work as a team on patient cases. "We want to bring those people under one umbrella."

Block said the hospital is using internal data reporting to monitor its progress on a regular basis, and better outcomes are already showing up in the results.

During 2005, there were 115,324 people admitted to California hospitals with coronary artery disease, which represented 7.3 percent of all adult nonmaterial admissions.

The data used in the reporting process had been criticized by medical providers throughout the state. Many physicians felt the hospitals couldn''t be compared fairly since some deal with patients who are much sicker than others. But with the help of established statistical formulas and better data collection methods the criticism has calmed down.

"Initially these reports were greeted with some skepticism, but they now accept it," Parker said. "The hospital association has supported the methods we employ.

"We are very proud of the quality of our data. We provide instruction for the nurses who collect the data, have automated checks, link it with patient discharge data and double check the data the hospitals send us."

Earlier research has shown that practice makes perfect, meaning hospitals with the largest heart volume have better outcomes. However, that school of thought is changing since researchers are finding that hospitals with low volume can have good outcomes when well-established best practices are used, Parker said.

—By Troy May

Troy May is the executive editor of the Healthcare Journal. You can reach him at tmay@healthcarejournalnorcal.com.